062566 Liberty Dialysis Colorado Springs Central (Fmc)

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 45020 Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition for Coverage §494.30 Infection Control, was out of compliance. V113 - Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. Based on observations, interviews, and document review, the facility failed to ensure five of six patients, who were observed after their dialysis treatment ended, performed hand hygiene prior to exiting the facility according to facility policy. V143 - [The facility must-] Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; Based on observations, document review, and interviews, the facility failed to ensure clinical staff demonstrated compliance when dispensing and administering intravenous (IV) medication from vials. Specifically, the facility failed to label an open multi-dose vial (MDV) with the date and time it was opened according to facility policy in two of two observations conducted in the medication preparation area.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 45020 Based on observations, interviews, and document review, the facility failed to ensure five of six patients, who were observed after their dialysis treatment ended, performed hand hygiene prior to exiting the facility according to facility policy. Findings include: Facility policy: The Hand Hygiene policy read, the purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination. All staff, patients, patient care givers, including physicians and non-physician practitioners, social workers, dietitians, and any other indirect patient care staff must follow the same requirements for hand hygiene. Patients should perform hand hygiene if able, prior to and after each dialysis treatment. As needed, direct patient care staff will demonstrate how to operate the sinks, demonstrate hand washing to patients who are able to perform hand washing, and explain the risk of contamination with regard to their vascular access and hands to all patients. To help ensure the prevention of cross contamination to their family members or other patients, hand hygiene must be performed. 1. The facility failed to ensure patients performed hand hygiene after treatment according to facility policy. A. Observations i. On 9/22/25 at 9:52 a.m., an observation was conducted at station #19. The patient was observed holding pressure to their own upper left thigh access site with gloved right and left hands following the removal of needles used for treatment. At 9:56 a.m., after stabilization of the sites, patient care technician (PCT) #4 applied a gauze dressing to the sites. The patient then removed the soiled gloves and without performing hand hygiene, gathered their belongings, ambulated to the scale, obtained their weight, and exited the facility. Staff did not educate or request the patient to perform hand hygiene following the glove removal. ii. On 9/22/25 at 10:05 a.m., an observation was conducted at station #21. The patient was observed holding pressure to their own access sites with a gloved right hand following the removal of the needles used for treatment. At 10:17 a.m., after stabilization of the sites, PCT #4 applied a gauze dressing to the sites. The patient then removed the soiled gloves and without performing hand hygiene, gathered their belongings, ambulated to the scale, obtained their weight, and exited the facility. Staff did not educate or request the patient to perform hand hygiene following the glove removal. iii. On 9/22/25 at 12:44 p.m., an observation was conducted at station #6. The patient was observed holding pressure to their own access sites with a gloved right hand following the removal of the needles used for treatment. At 1:10 p.m., after stabilization of the sites, PCT #5 applied a gauze dressing to the sites. Without removing their glove, the patient ambulated to the scale and obtained their weight. The patient removed their soiled glove at the scale, ambulated back to station #6, gathered their belongings, touched the automatic door opening button, and exited the facility. Staff did not educate or request the patient to perform hand hygiene following the glove removal. iv. On 9/23/25 at 9:32 a.m., an observation was conducted at station #10. The patient received dialysis treatment through a central venous catheter (CVC) (a thin, flexible tube inserted into a large vein near the heart). PCT #6 assisted the patient with gathering their belongings and oxygen tank. The patient ambulated to the scale, obtained their weight, touched the automatic door opening button, and exited the facility. Staff did not educate or request the patient to perform hand hygiene following the glove removal. v. On 9/23/25 at 9:42 a.m., an observation was conducted at station #12. The patient was observed holding pressure to their own access sites with a gloved right hand following the removal of the needles used for treatment. At 9:51 a.m., after stabilization of the sites, PCT #7 applied a gauze dressing to the sites. The patient then removed the soiled gloves, ambulated to the scale, obtained their weight, ambulated back to station #12, and gathered their belongings. The patient touched the automatic door opening button and exited the facility. Staff did not educate or request the patient to perform hand hygiene following the glove removal. B. Interviews i. On 9/23/25 at 1:35 p.m., an interview was conducted with PCT #8. PCT #8 stated patients were to perform hand hygiene before and after dialysis treatments. PCT #8 stated hand sanitizer was to be offered to patients because there was a risk of infections, which could cause illnesses such as flu and coronavirus disease (COVID). ii. On 9/23/25 at 1:57 p.m., an interview was conducted with registered nurse (RN) #9. RN #9 stated patients were to perform hand hygiene before leaving the facility because there was a risk of bacteria or blood on patients’ hands. RN #9 stated patients were to perform hand hygiene before and after each treatment. RN #9 stated if a patient did not perform hand hygiene after treatment, there was a risk of infection, such as hepatitis (a liver disease).”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 45020 Based on observations, document review, and interviews, the facility failed to ensure clinical staff demonstrated compliance when dispensing and administering intravenous (IV) medication from vials. Specifically, the facility failed to label an open multi-dose vial (MDV) with the date and time it was opened according to facility policy in two of two observations conducted in the medication preparation area. Findings include: Facility policy: The Medication Preparation and Administration policy read, the purpose of this policy is to administer medications with the goals of staff and patient safety, optimal therapeutic response and infection control. When preparing medications, if the vial is not used immediately in its entirety, the nurse or patient care technician (PCT) must place the date and time the vial was opened on the medication label along with their initials. To ensure all open vials are properly marked, the nurse must never walk away from an opened multi-dose vial without writing the date and time the vial was opened. Label any open multi-dose vial that is not used immediately and store vial accordingly. 1. Facility staff failed to label an open multi-dose vial of medication with the date and time it was opened according to facility policy. A. Observations i. On 9/22/25 at 11:45 a.m., and on 9/23/25 at 7:26 a.m., observations of the facility’s medications revealed an open MDV of sodium citrate (a medication to prevent blood clots) in a drawer in the medication preparation area. There was no date or time on the vial to indicate when the medication had been opened. During the observation on 9/23/25, registered nurse (RN) #1 stated they were unsure of the date or time the vial had been opened, and there was a risk the medication could have lost effectiveness. B. Interviews i. On 9/24/25 at 9:49 a.m., an interview was conducted with PCT #2. PCT #2 stated when a MDV was opened, the staff member was expected to label the vial with the date, time, and their initials. PCT #2 stated if the vial was not dated when it was opened, there was a risk the medication could lose effectiveness and not perform as intended. ii. On 9/23/25 at 1:57 p.m., an interview was conducted with RN #3. RN #3 stated MDV medications were to be labeled with the date it was opened to ensure expired medications were not administered to patients. RN #3 stated expired medications could contain bacteria. RN #3 also stated patients were at risk for missed dialysis treatments, infections, and death if expired medications were administered.”